Extracorporeal pneumoperitoneum enclosure and method of use

ABSTRACT

Surgical apparatus for providing extracorporeal pneumoperitoneum. One embodiment provides a reversely turned fluid and gas impermeable fingerless sleeve ( 14 ) with a quick connect and disconnect assembly around the cuff of the sleeve ( 14 ) for sealing around an abdominal incision to allow hand-assisted minimally invasive surgery under conditions of pneumoperitoneum. A dome shaped enclosure ( 62 ) is provided for use with the quick connect and disconnect assembly to seal around an abdominal incision and maintain pneumoperitoneum during interruptions in a surgical procedure. Another embodiment incorporates a fingerless sleeve ( 14 ) which is adhesively secured directly to a patient&#39;s skin around an incision. The sleeve is applied over a pre-gloved surgeon&#39;s hand, and an outer surgical glove ( 18 ) is applied over the sleeve ( 14 ) in the region where the fingers and thumb protrude before the sleeve ( 14 ) is reversely turned on itself for connection to a patient.

CROSS-REFERENCE TO RELATED APPLICATIONS

This is a 371 of PCT/US97/18168, filed Oct. 8, 1997, which claims thebenefit of the priority of U.S. patent application Ser. No. 08/801,752,filed Feb. 18, 1997.

FIELD OF THE INVENTION

The present invention relates generally to an apparatus and methodsuitable for maintaining extracorporeal pneumoperitoneum at an abdominalfenestration during surgery, and more particularly to a quick connectand disconnect enclosure and method for insertion of instruments or asurgeon's hand into the body cavity through a fenestration for access toorgans and instruments within the cavity without loss of insufflationpressure.

BACKGROUND OF THE INVENTION

Laparoscopy and endoscopy have become a preferred surgical procedurebecause it is minimally invasive of the patient's body and, in manyinstances, can be performed in short-procedure facilities with minimaltrauma and significantly reduced recuperation time. In some cases, a newprocedure referred to as hand-assisted laparoscopy, or endoscopy, hasbeen employed in which a small muscle splitting incision is made justlarge enough for admitting the surgeon's hand into the abdominal cavityto enable palpation of organs and manipulation of surgical instruments,and to provide bio-physical feedback. Visual feedback is usuallyprovided as well through an endoscope and TV monitor.

Several medical devices have been developed which make it possible forhand-assisted laparoscopy to be carried out in the abdominal cavitywhile under conditions of pneumoperitoneum. One device, for instance, byPatrick F. Leahy et al. disclosed in U.S. patent application Ser. No.08/300,346 filed Mar. 29, 1995 (International Application PCT/US95/04202published Oct. 29, 1995) provides a gas-tight sleeve which communicateswith the abdominal cavity through an incision allowing the surgeon'shand access through entry and exit openings at opposite ends of thesleeve. The exit opening is sealed around the incision by a flangeadhesively attached to the external surface of the abdomen. After thehand is passed through the entry opening, the sleeve is sealed aroundthe surgeon's forearm by an adjustable cuff. A duckbill check valvedisposed between the entry and exit openings forms with the exit openinga substantially gas-tight chamber which allows the surgeon to withdrawhis hand from the insufflated cavity with only a slight drop in gaspressure which can be quickly restored.

Another device disclosed in U.S. Pat. No. 5,480,410 to Cuschieri et al.provides a gas-tight enclosure in which a resilient ring at an exitopening is squeezed by hand into an oblong shape for insertion throughthe abdominal incision, then allowed to expand to its original shapeunder the edge of the incision to seal the peritoneum and enclosure forsufflation. At least one entry opening is provided for passing aninstrument or a surgeon's hand into the enclosure. The enclosure mayalso include a surgical glove integrally sealed to the entry opening ina glove-box manner for allowing the surgeon's hand sterile accessthrough the exit opening to organs and instruments within the abdominalcavity.

None of these devices, however, satisfies the need for such a gas-tightenclosure which can be quickly disconnected and reconnected as often asnecessary during hand-assisted laparoscopic or endoscopic surgery whilethe enclosure remains sealed in place around the surgeon's hand, andwhich can maintain abdominal pneumoperitoneum during extendedinterruptions in an operation for other medical procedures.

OBJECTS OF THE INVENTION

Accordingly, it is an object of the present invention to provide agas-tight extracorporeal pneumoperitoneum enclosure which is worn by thesurgeon during hand-assisted laparoscopic or endoscopic surgery, whichcan be quickly disconnected from a patient as often as necessary in thecourse of an operation and reconnected while still sealed around thesurgeon's hand, which allows the surgeon to manipulate or palpate organsand instruments from within the abdominal cavity, and which providesbio-physical feedback from the surgeon's hand under conditions ofpneumoperitoneum.

Another object of the invention is to provide a surgical apparatus whichcan be continuously sealed around the surgeon's hand and forearm andselectively connected around an open wound while maintainingpneumoperitoneum in the course of a hand-assisted laparoscopic orendoscopic operation, and which will maintain pneumoperitoneum withinthe body cavity during any interruptions for any other medical procedurein the course of an operation.

A still further object of the invention is to enable minimally invasivesurgery with minimal risk of damage to the immune system, and withshorter healing time and less time needed for recuperation in ahospital.

A further object is to provide a disposable surgical device which isrelatively simple in design and easy to use.

SUMMARY OF THE INVENTION

More specifically, in one embodiment, the extracorporealpneumoperitoneum enclosure is a fluid and gas impermeable elongatefingerless sleeve having an open proximal end and a distal end withholes arranged to seal gas-tightly around the base of the surgeon'sthumb and each of the fingers. The sleeve section intermediate its endsis reversely-turned on itself before its proximal end is fastened eitherdirectly, or indirectly, onto a patient's skin around an incision.Preferably, a quick connect and disconnect assembly at the proximal endof the sleeve gas-tightly seals to the skin around an incision allowingthe surgeon to interrupt and resume a hand-assisted laparoscopicsurgical procedure under conditions of pneumoperitoneum as often asneeded without removing the sleeve from his/her hand. Integral with thequick connect and disconnect assembly is a pressure relief valve forpreventing over-sufflation. At least one instrument port is provided inthe cuff for admitting, without loss of gas pressure, surgicalinstruments.

In another embodiment of the extracorporeal pneumoperitoneum enclosure,a fluid and gas impermeable hemispheric envelope is sealed gas-tightlyaround the incision. A quick connect and disconnect assembly withintegral pressure relief valve is secured around an open base formaintaining the abdominal cavity sufflated during interruptions in anoperation. This embodiment also includes a sealable instrument port.

Upper and lower seal rings in both embodiments of the quick connect anddisconnect assembly have respectively mating interfaces enabling thesleeve and envelope to be interchangeable without removing the lowerseal ring previously attached to a patient.

The method for using the apparatus in a hand-assisted laparoscopicoperation is as follows. A lower seal ring of the quick connect anddisconnect assembly is adhesively sealed to the skin of the patientaround the site where a small muscle-splitting incision is made throughthe abdomen wall and peritoneum. A wound liner and retractor may beinserted into the incision to protect the wound from contamination andto spread it apart for easier access. Wearing an inner surgical glove,the surgeon inserts his/her hand into the fingerless sleeve until thefingers extend completely through the holes and become tightly sealedaround their bases. For extra precaution against leakage, an outersurgical glove is then placed over both the inner glove and thefingerless sleeve. The sleeve is then reversely turned on itself. Anupper seal ring of the quick connect and disconnect assembly around thecuff of the glove is then sealingly interconnected with the lower sealring and the abdomen and glove insufflated to the desired pressureeither through a separate cannula or a port in the glove. The surgeon'shand may then be inserted into the abdominal cavity and removed as oftenas necessary during a laparoscopic procedure. The port in the sleevepermits instruments to be inserted as often as needed. Any increase insufflating gas pressure, caused by a sudden reduction in volume wheninserting the hand, is prevented by the pressure relief valve in thequick connect and disconnect assembly.

Whenever the surgeon wishes to interrupt a surgical procedure whilestill maintaining pneumoperitoneum, the sleeve is disconnected from thelower seal ring, and in its place the dome-like envelope with upper sealring are connected to the lower seal ring left on the abdomen andsufflation restored.

Other objects, advantages and novel features of the invention willbecome apparent from the following detailed description of the inventionwhen considered in conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a view in elevation and partial cross section of anextracorporeal pneumoperitoneum enclosure, or sleeve, according to oneembodiment of the invention as applied in hand-assisted laparoscopicsurgery in the abdomen;

FIG. 2 is perspective view of various components of the sleeve, orenclosure, of FIG. 1 spatially arranged in order of assembly;

FIG. 3 is a more detailed view, partially in cross section, of a segmentof a connect and disconnect assembly shown connected in the enclosure ofFIG. 1;

FIG. 4 is a cross sectional view like FIG. 3 but with the assembly shownpartially disconnected;

FIG. 5 is a view in cross section of an upper seal ring of the sleeve,or enclosure, taken along the line 5—5 of FIG. 2;

FIG. 6 is a plan view of a lower seal ring with an integral reliefvalve;

FIG. 7 is a view in cross section of an instrument port shown in theenclosure of FIG. 1;

FIG. 8 is a view of the instrument port of FIG. 7 view from within theenclosure of FIG. 1;

FIG. 9 is a view in elevation and partial cross section of anextracorporeal pneumoperitoneum enclosure according to anotherembodiment of the invention as applied during an interruption of asurgical procedure;

FIG. 10 is a perspective view of an enclosure, or sleeve, similar to theembodiment of FIG. 1, but utilizing a simplified connect and disconnectassembly; and

FIG. 11 is a partially-sectioned elevational view showing the enclosure,or sleeve, of FIG. 10 reversely turned and in use in an operatingposition.

DETAILED DESCRIPTION

Referring now to the drawings, FIG. 1 illustrates an extracorporealpneumoperitoneum enclosure 10 according to the invention applied to apatient's anterior abdominal wall W. A surgeon's hand extends into theabdominal cavity through a small muscle splitting incision which isprotected from wound contamination by a wound protector/retractor 12such as disclosed in U.S. Pat. No. 5,524,644 to Berwyn M. Crook.

In one preferred embodiment, enclosure 10 includes an elongate gasimpermeable flexible sleeve 14 of sufficient length to receive the handand forearm of the surgeon. Sleeve 14 has an intermediate section thatextends from a proximal end cuff section 14 a to a “fingerless,” distal,hand section 14 b where it terminates with holes 15 positioned toreceive the full length of the surgeon's thumb and fingers and to sealthe sleeve snugly around the root of each as shown in FIG. 2.

As best seen in FIG. 2, sleeve 14 has an inner side 14 c which facesoutward in FIG. 1 because, in use, the intermediate cuff section isinverted, or reversely-turned on itself, so that the inside faces out.An inner surgical glove 16, worn in direct contact with the hand, iscontiguous with inner side 14 c, and an outer surgical glove 18, worn toensure against leakage at holes 15, covers an outer side 14 d. Thus, thedistal end portion 14 b of the sleeve 14 is sandwiched between the innerand outer surgical gloves 16 and 18, respectively and thereby secured inplace.

Sleeve 14 is made of surgical grade supple transparent material in onesize designed to seal around the fingers of a small hand but which willalso stretch slightly under plastic deformation with residual elasticityto accommodate larger hands without constricting circulation to thefingers. A suitable material is 2 mil thick polyethylene film such asX-2000 by Pierson Industries. The preferred diameters of the holes 15,in inches, are as follows: thumb 0.98, index finger 0.79, middle finger0.87, ring finger 0.75, and pinky 0.63.

In the embodiments of FIGS. 1-9, an annular quick connect and disconnectcoupling means assembly 20 is permanently sealed around the proximal endof cuff section 14 a and removably sealed with an adhesive 22 to theabdominal skin around the protector/retractor 12.

Referring to FIGS. 3-6, coupling assembly 20 includes interconnectingupper and lower seal rings 20 a and 20 b, preferably molded of a medicalgrade flexible, slightly resilient thermoplastic rubber of Shore 80Ahardness such as Santoprene® made by Advanced Elastomer Systems. Upperring 20 a defines an annular collar 24 permanently sealed around theperiphery of cuff section 14 a with an upwardly facing annular bead 26concentrically disposed around collar 24.

Lower ring 20 b includes an annular flange 28 having adhesive 22 forsecuring ring 20 b to the skin of a patient during surgery. A peel strip30 (FIG. 2) covers the adhesive until the ring is to be applied to theskin of the abdomen. A preferred adhesive is IT8-59-A by Tolas HealthCare Packaging of Feasterville, Pa. An annular member 32 sealed aroundits bottom to flange 28 extends upward and terminates in a downwardlyfacing annular groove 33 formed to interface in a tight seal with bead26 of upper ring 20 a. An annular detent 34 extending radially from bead26 snaps into an annular groove 36 on the inner surface of member 32when bead 26 and groove 33 are positively engaged as shown in FIG. 3.Pull tabs 38 extending inward from cylinder 24 enable the surgeon'sfingers to pull detent 34 inward and disengage it from groove 36,thereby releasing upper ring 16 a from lower ring 20 b as shown in FIG.4.

Lower ring 2 b further includes a normally closed gas pressure reliefvalve 40 for limiting increases in pressure in the abdominal cavity asmay be caused when the surgeon inserts his/her hand and displaces thesleeve 14. The valve 40 comprises a seat 42 integrally molded in theperiphery of lower ring 20 b, a cap 44, a poppet valve 46, and a helicalspring 48. Cap 44 is secured to ring 16 b by turning it about itscylindrical axis until tabs 43 a on the bottom edge mate with slots 43 baround seat 42. An aperture 44 a in the top of cap 44 guides a stem 46 aof plunger 46 onto seat 42 as well as serves as a vent for sufflationgas released through valve 40. Spring 48, around stem 46 a between thetop of cap 44 and a head 46 b of plunger 46, biases valve 40 to anormally closed position. A recess 43 in the surface beneath seat 42 bforms a channel 47 with flange 28 for continuously communicating betweenvalve 40 and the abdominal cavity when lower seal ring 20 b is adheredto the surface of the abdomen. If the cavity pressure exceeds a safelimit for pneumoperitoneum, e.g. 30 mm Hg, plunger 46 lifts off of seal42 against the force of spring 48 to release the gas to ambientatmosphere. The materials of construction for cap 44 and plunger 46 arepreferably a rigid thermoplastic polycarbonate of Shore 80C hardness.

FIGS. 10 and 11 illustrate a simplified annular assembly means 70 forsecuring sleeve 14 directly to a patient. The assembly 70 includes aannular flange 72 of flexible plastic permanently heat-sealed or bondedaround the proximal end of sleeve cuff section 14 a. An adhesive 74 iscoated on the bottom side of flange 72 for applying either directly tothe patient's skin, or to a surgical drape, around the site of theincision. Complementary peelable strips 76 around respective halves ofthe flange cover the adhesive until the glove is ready for attachment tothe skin or drape. A boss, that may mount either a pressure relief valve40, as previously discussed, or provide a sealed instrument port 50, aswill be discussed, may be provided in the sleeve 14 adjacent itsproximal end as shown in FIG. 10. A preferred material for flange 72 isa 4 mil plastic laminate of EVA/Surlyn®/EA, and a preferred adhesive isIT8-59-A supra.

Sleeve 14 includes an instrument port 50 located close to the proximalend of cuff section 14 a to provide an optional entry into the abdominalcavity for instruments such as graspers, staplers, clip appliers,scopes, etc. Referring to FIGS. 7 and 8, port 50 includes a generallycylindrical housing 52 with a first flanged base 52 a at one end securedto the inner side 14 c of cuff section 14 a. The other end defines acone-shaped wall 52 b tapering along its conical axis into the housingto a circular hole 54 at the small end which is sized for slidablyreceiving an instrument without leakage. A duckbill check valve 56prevents pressure loss when no instrument is present in port 50. Theduckbill check valve 56 comprises a second flanged base 56 a at one endsecured to the inside of the housing 52 adjacent to wall 52 b. The otherend tapers to a normally closed slit 56 b spaced below hole 54 in aplane transverse to the conical axis of wall 52 b. Housing 52 and insert56 have sufficient resilience for wall 52 b to form a gas-tight sealaround the instrument's surface and to ensure that slit 56 b closestightly after the instrument is withdrawn. A suitable material found forthis purpose is a molded thermoplastic rubber such as Santoprene® byAdvanced Elastomer Systems.

FIG. 9 illustrates an alternate embodiment of an extendedpneumoperitoneum enclosure 60 according to the invention for use inplace of the glove enclosure 10 during interruptions in surgeryconducted under pneumoperitoneum conditions. It comprises a hemisphericdome-shaped envelope 62 of thin transparent flexible polyethylene filmand an upper seal ring 64 of like construction as upper seal ring 20 a.The perimeter at the open base is sealed around upper seal ring 64 andinterconnects with lower seal ring 20 b of assembly 20. Of course,enclosure 60 may also include its own lower seal ring such as utilizedin the FIGS. 10 and 11 embodiment. Access by surgical instruments isprovided by an instrument port 66, like port 50, secured to envelope 62.

A method according to the invention for performing hand-assistedabdominal laparoscopic surgery utilizing the extended pneumoperitoneumenclosures as above-described will now be described.

The site for making the incision is precisely traced on the abdomen ofthe patient. In the embodiment of FIGS. 1-8, seal ring 20 b and sleeve14 are preferably separated from upper seal ring 20 a and placed on thesurgeon's hand before ring 20 a is attached to the abdomen in order toafford a more clear unobstructed view of the tracing. Peel strip 30covering adhesive 22 on lower ring 20 b is removed and the ring adheredto the abdomen around the tracing.

Guided by the tracing, a small muscle-splitting incision is made throughthe abdomen wall sufficient in size to allow the surgeon's hand to passthrough. The peritoneum is incised roughly the same amount. Wound linerand retractor 12 is installed in the incision to protect the wound fromcontamination and to spread it apart for easier access by the hand. Theabdomen wall and peritoneum may also be punctured at other locations forreceiving an insufflator, a laparoscope and other instruments.

Wearing an inner surgical glove 16, the surgeon dons sleeve 14 byplacing his/her hand into fingerless hand section 14 b until the thumband fingers extend completely through holes 15 and become snugly sealedthereby. Cuff section 14 a and upper ring 20 a (or assembly 70 of FIG.10) are drawn up over the forearm exposing the outer side 14 d offingerless section 14 a. For added protection against leakage aroundholes 15, an outer surgical glove 18 is preferably placed over theexposed finger portions of inner glove 16 and hand section 14 a. Ifpreferred, the surgeon may don the sleeve 14 and attach it to the lowerring 20 b before incising the abdomen.

The sleeve 14 is then reversely turned on itself with the cuff section14 a inverted and upper ring 20 a is sealed in lower ring 16 b bypressing bead 26 into recess 33 until detent 36 of upper ring 20 a snapsinto groove 36 of lower ring 20 b. The abdominal cavity and the annularenvelope formed by sleeve 14 may now be insufflated to the desiredpressure either through a separate cannula or through port 50 in sleeve14. The thus-covered surgeon's hand may thereafter enter and re-enterthe abdominal cavity as often as necessary during the surgery withoutlosing pneumoperitoneum. Any increase in insufflating gas pressure, suchas caused by a reduction in volume inside the sleeve-formed chambersurrounding the surgeon's forearm when inserting the hand, is relievedby pressure relief valve 40.

Should an extended interruption in a surgical procedure be needed whilestill maintaining pneumoperitoneum, sleeve 14, attached to upper sealring 20 a, may be disconnected leaving in place lower seal ring 20 b.Dome-shaped envelope 62, attached to upper seal ring 64, may then beconnected to lower seal ring 20 b and insufflation restored.

Of course, when using the embodiment of FIGS. 10 and 11, the surgeonwould don the sleeve 14, as described above, peel strips 76 from theadhesive 74 and place the flange directly on the skin or surgical drapearound the incision site after the wound liner and retractor 12 has beeninstalled.

Some of the many advantages and novel features of the invention shouldnow be readily apparent. For example, an extracorporeal pneumoperitoneumenclosure is provided which can be continually worn by the surgeonduring hand-assisted laparoscopic surgery under conditions ofpneumoperitoneum without loss of free hand and finger movement. Itallows the surgeon to quickly disconnect and reconnect the enclosurefrom the patient while still retaining it on his/her hand. An alternateembodiment provides a dome-like enclosure which can be substituted forthe sleeve whenever a protracted interruption in a surgical procedure isnecessary. It enables minimal invasive surgery and risk of damage to apatient's immune system. Due to the smaller incisions, shorter healingtime and less time for recuperation in the hospital is possible. Theenclosures are also relatively simple in design and easy to use.

It will be understood, of course, that various changes in the details,materials, steps and arrangement of parts which have been hereindescribed and illustrated in order to explain the nature of theinvention may be made by those skilled in the art within the principleand scope of the invention as expressed in the appended claims.

What is claimed is:
 1. Apparatus for use in providing extracorporealpneumoperitoneum around a surgical incision in a patient, comprising: anelongate flexible sleeve (14) having a distal end portion (14 b) forcovering a surgeon's hand, an intermediate portion for covering thesurgeon's forearm, and a proximal portion (14 a) having an end openingenabling insertion of the surgeon's hand and forearm, and means forreleasably gas-tightly securing said proximal portion (14 a) end openingto the patient around the surgical incision and enabling saidintermediate portion to be reversely turned to extend along thesurgeon's forearm when said sleeve (14) is operatively secured to thepatient and insufflated; said distal portion (14 b) of said flexiblesleeve (14) having a plurality of openings (15) for receiving asurgeon's fingers and thumb; and said sleeve (14) being formed of suppleplastic which conforms, but does not continuously constrict, about thebases of the fingers and thumb when the sleeve is installed and thesurgeon's hand clasped.
 2. Apparatus according to claim 1, wherein saidplastic material is a polyethylene film.
 3. Apparatus for use inproviding extracorporeal pneumoperitoneum around a surgical incision ina patient, comprising: an elongate flexible sleeve (14) having a distalend portion (14 b) for covering a surgeon's hand, an intermediateportion for covering the surgeon's forearm, and a proximal portion (14a) having an end opening enabling insertion of the surgeon's hand andforearm, and means for releasably gas-tightly securing said proximalportion (14 a) end opening to the patient around the surgical incisionand enabling said intermediate portion to be reversely turned to extendalong the surgeon's forearm when said sleeve (14) is operatively securedto the patient and insufflated, said distal portion (14 b) of saidflexible sleeve (14) having a plurality of openings (15) for receiving asurgeon's fingers and thumb, and the diameters of said openings (15), ininches, being as follows: thumb 0.98, index finger 0.79, middle finger0.87, ring finger 0.75 and pinky 0.63.
 4. Apparatus for use in providingextracorporeal pneumoperitoneum around a surgical incision in a patient,comprising: an elongate flexible sleeve (14) having a distal end portion(14 b) for covering a surgeon's hand, an intermediate portion forcovering the surgeon's forearm, and a proximal portion (14 a) having anend opening enabling insertion of the surgeon's hand and forearm, andmeans for releasably gas-tightly securing said proximal portion (14 a)end opening to the patient around the surgical incision and enablingsaid intermediate portion to be reversely turned to extend along thesurgeon's forearm when said sleeve (14) is operatively secured to thepatient and insufflated, said means including an annular base (20 b)adapted to be adhesively secured to the patient around the incision andan annular ring (20 a) connected to said sleeve (14) and releasablyengageable with said base (20 b), and said annular base (20 b) having apressure relief valve (40) for relieving overpressures above about 30 mmHg.
 5. Apparatus according to claim 4, wherein said annular ring (20 a)matingly engages interiorly of said base (20 b) in gastight relationtherewith.
 6. Apparatus according to claim 4, wherein said annular ring(20 a) has at least one inwardly-extending pull tab (38) affordingdisengagement of said annular ring (20 a) from said annular base (20 b).7. Apparatus according to claim 4, wherein said pressure relief valve(40) has a cap (44) with an aperture (44 a), a plunger (46) with a head(46 b) confined by said cap (44) and a stem (46 a) extending through andbeyond said aperture (44 a) for being guided by said aperture (44 a),and a spring (48) extending about said stem (46 a) between said head (46b) and cap (44).
 8. Apparatus according to claim 9, wherein said annularring (20 a) has at least one inwardly-extending pull tab (38) affordingdisengagement of said annular ring (20 a) from said annular base (20 b).9. Apparatus for use in providing extracorporeal pneumoperitoneum arounda surgical incision in a patient, comprising: an elongate flexiblesleeve (14) having a distal end portion (14 b) for covering a surgeon'shand, an intermediate portion for covering the surgeon's forearm, and aproximal portion (14 a) having an end opening enabling insertion of thesurgeon's hand and forearm, means for releasably gas-tightly securingsaid proximal portion (14 a) end opening to the patient around thesurgical incision and enabling said intermediate portion to be reverselyturned to extend along the surgeon's forearm when said sleeve (14) isoperatively secured to the patient and insufflated, said means includingan annular base (20 b) adapted to be adhesively secured to the patientaround the incision and an annular ring (20 a) connected to said sleeve(14) and releasably engageable with said base (20 b), and a closure (60)releasably engageable with said base (20 b) affording selective sealedconnection thereto of either said sleeve (14) or said closure (60). 10.Apparatus according to claim 9 wherein said closure (60) includes aflexible hemispheric dome (62) overlying said base ring (20 b). 11.Apparatus according to claim 10 wherein said closure (60) includes aport (66) having an interiorly-opening duckbill check valve (56)affording passage of a surgical instrument into the closure (60). 12.Apparatus for use in providing extracorporeal pneumoperitoneum around asurgical incision in a patient, comprising: an elongate flexible sleeve(14) having a distal end portion (14 b) for covering a surgeon's hand,an intermediate portion for covering the surgeon's forearm, and aproximal portion (14 a) having an end opening enabling insertion of thesurgeon's hand and forearm, said distal portion (14 b) having aplurality of openings (15) for receiving a surgeon's fingers and thumb,means for releasably gas-tightly securing said proximal portion (14 a)end opening to the patient around the surgical incision and enablingsaid intermediate portion to be reversely turned to extend along thesurgeon's forearm when said sleeve (14) is operatively secured to thepatient and insufflated, an outer surgical glove (18) applied on saidsurgeon's hand after being operatively inserted into said distal portion(14 b) of said sleeve and through said openings (15) for ensuring sealedclosure of said openings (15), and an inner surgical glove (16) disposedon the surgeon's hand inwardly adjacent said sleeve distal portion (14b) for cooperating with said outer surgical glove (18) to sandwich saidsleeve distal end (14 b) therebetween.
 13. Apparatus for preventingover-insufflation of a body cavity during endoscopic surgery,comprising: a flexible sleeve (14) having one end portion (14 a)operatively sealingly connected to a patient around an incision andanother end portion (14 b) operatively sealingly connected to a surgeon,a pressure relief valve (40) having an inlet in gas communication withthe interior of said sleeve (14) and having an outlet to ambientatmosphere, and means for biasing said pressure relief valve (40) into aclosed position normally blocking flow from the inlet to the outletuntil a predetermined pressure level is reached within said sleeve (14)at which time said pressure relief valve permits gas to flow from saidinlet to said outlet, whereby over-insufflation of the body cavity canbe avoided during endoscopic surgical movements of the surgeon. 14.Apparatus according to claim 13, wherein said pressure relief valve (40)has a cap (44) with an aperture (44 a) and a plunger (46) with a head(46 b) confined by said cap (44) and a stem (46 a) extending through andbeyond said aperture (44 a) for being guided by said aperture (44 a),and wherein said means for biasing said pressure relief valve (40) is aspring (48) extending about said stem (46 a) between said head (46 b)and cap (44).
 15. Apparatus according to claim 13 wherein said pressurerelief valve (40) includes a base (20 b) releasably connectable to thepatient in proximity with the incision.
 16. Apparatus according to claim15 wherein said base (20 b) is formed integral with a ring surroundingsaid incision and adhesively securable to the patient.
 17. Apparatusaccording to claim 13 wherein said predetermined pressure is less thanabout 30 mm Hg.
 18. Apparatus according to claim 16 including a closure(60) having a self-sealing instrument port (66), said closure (60) beingreleasably engageable with said ring (20 b) for affording selectiveengagement of either said closure (60) or said sleeve (14) on said ring(20 b).
 19. Apparatus according to claim 13 wherein said flexible sleeve(14) has an intermediate portion reversely turned on itself to form avariable volume annular chamber around the surgeon's forearm. 20.Apparatus for providing extracorporeal pneumoperitoneum around asurgical incision, comprising: a flexible gas impermeable envelope (14)having a proximal section (14 a) defining a proximal end opening, adistal section (14 b) with holes (15) for receiving a surgeon's digits,and an intermediate section reversely turnable about the surgeon'sforearm with the distal section (14 b) telescopically moveable into theproximal section (14 a); ring means (20) carried by said envelope (14)about said proximal end opening for securing said envelope (14) insealing contact with skin around the incision; and a pressure reliefvalve (40) carried by said ring means (20) for communicating with saidenvelope (14) to vent insufflated gas when its pressure exceeds apre-selected limit.
 21. Apparatus according to claim 20, wherein saidpressure relief valve (40) has a cap (44) with an aperture (44 a), aplunger (46) with a head (46 b) confined by said cap (44) and a stem (46a) extending through and beyond said aperture (44 a) for being guided bysaid aperture (44 a), and a spring (48) extending about said stem (46 a)between said head (46 b) and cap (44).
 22. Apparatus according to claim23, wherein said ring (20 a) mounted on said envelope proximal end hasat least one inwardly-extending pull tab (38) affording disengagement ofsaid ring (20 a) from said other ring (20 b).
 23. Apparatus according toclaim 20 wherein said ring means (20) includes releasably matinglyengageable rings (20 a, 20 b), one mounted on said envelope proximal endand the other adhesively connectable to said skin.
 24. Apparatusaccording to claim 23 including a closure (60) having a ring (64 a),like in construction to said one ring, for enabling said closure (60) tobe selectively mounted onto said skin adhered ring.
 25. Apparatusaccording to claim 24 including: a bead (26) formed in said one ringaround said envelope proximal end opening; and a groove (33) formed insaid other ring for interengaging said bead (26).
 26. Apparatusaccording to claim 25 further comprising: detent means (34, 36) formedin said rings for interlocking when said bead (26) and said groove (33)are fully engaged.
 27. Apparatus according to claim 20, wherein saidpreselected pressure limit is approximately 30 mm Hg.
 28. Apparatusaccording to claim 20 further comprising: a port (50) fixed to saidenvelope (14) and formed to admit a surgical instrument whilemaintaining extracorporeal pneumoperitoneum.
 29. Apparatus according toclaim 28 wherein said port means (50) further includes: a generallycylindrical housing (52) having a conical wall (52 b) tapering inward toform a circular hole (54) for slidably receiving said surgicalinstrument; a duckbill check valve (56) secured to said housing (52) andhaving a normally closed slit spaced below said hole (54) in a planetransverse to a conical axis of said wall (52 b) for slidably receivingthe instrument in series with said hole (54).
 30. Apparatus according toclaim 29 wherein: said housing (52) has sufficient resilience for saidhole (54) to form a gas-tight seal around the instruments' surface; andsaid duckbill check valve (56) has sufficient resilience for said slitto close tightly upon itself when the instrument is withdrawn therefrom.31. Apparatus for hand-assisted minimally invasive surgery underconditions of pneumoperitoneum, comprising: a gas impermeable flexiblesleeve (14) having a fingerless distal hand section (14 b) terminatingin holes (15) for receiving the thumb and fingers of a surgeon's hand,an intermediate cuff section extending from said distal hand section (14b), and a proximal end section (14 a) terminating in an opening, saidintermediate cuff section being reversely turnable on itself forextending along the surgeon's forearm when the proximal end opening (14a) is displaced toward the distal end (14 b), a peelable adhesive ring(20 b) carried by said sleeve (14) for sealing contact with skin aroundan abdominal incision; and means for releasably coupling said adhesivering (20 b) to said sleeve (14) about its proximal end opening. 32.Apparatus according to claim 31 wherein said releasable coupling meansincludes a first ring (20 a) sealed to said sleeve (14) about itsproximal end opening for releasably sealingly engaging interiorily ofsaid adhesive ring (20 b).
 33. Apparatus according to claim 31 includingpressure relief valve means (40) carried by said adhesive ring (20 b)for relieving pressure above a predetermined level occurring inside saidreversely turned sleeve (14).
 34. Apparatus according to claim 31including an outer surgical glove (18) encasing the surgeon's hand afterinsertion through the distal end holes (15) for effecting a positiveseal of the holes (15).
 35. Apparatus according to claim 34 including aninner surgical glove (16) encasing the surgeon's hand interiorily of thesleeve (14) for sandwiching the sleeve distal end (14 b) between innerand outer surgical gloves (16, 18).
 36. Apparatus according to claim 32,wherein said first ring (20 a) has at least one inwardly-extending pulltab (38) affording disengagement of said first ring (20 a) from saidadhesive ring (20 b).
 37. Apparatus according to claim 33, wherein saidpressure relief valve means (40) has a cap (44) with an aperture (44 a),a plunger (46) with a head (46 b) confined by said cap (44) and a stem(46 a) extending through and beyond said aperture (44 a) for beingguided by said aperture (44 a), and a spring (48) extending about saidstem (46 a) between said head (46 b) and cap (44).